How the Flexner Report Whipped Medical Education Into Shape

Why you should care

Because medical training didn’t always have rigorous standards — or any standards, period.

By Melissa Pandika

The Daily DoseMAY 15 2014

As a molecular and cell biology major — who briefly toyed with applying to med school — I still vividly remember walking into lecture halls a few minutes before class, past rows of pre-med students burrowed nose-deep in MCAT test prep books. Now in their last year of medical school, they post Facebook statuses lamenting their round-the-clock clinical rotations.

More than a third of medical schools — which had failed to meet the report’s standards — shut down as a result.

As any stressed-out, overly caffeinated pre-med student will tell you, medical school in the U.S. is extremely competitive. Prospective applicants need to take a suite of undergraduate science classes, earn high GPAs and MCAT scores and more. Medical students take two years of lecture and lab courses, followed by two more years of clinical rotations. And many complete additional training to specialize in pediatrics or radiology, for example. It’s no surprise that medicine is a prestigious, well-paid profession, or that the cost of health care is so high.

Source Rockefeller Foundation Archive

But medical training didn’t always have such rigorous standards — or standards, period. In the 19th century, medical schools were flooding the country with poorly trained physicians. Many medical schools were for-profit, physician-owned “proprietary” schools unaffiliated with a university. The owners taught in crowded lecture halls, and rarely offered lab courses, or even opportunities for patient contact. Students were often admitted with only a high school education or less.

That all changed in 1909, when the Carnegie Foundation asked Kentucky high school teacher Abraham Flexner to survey the quality of all 155 medical schools in North America and offer suggestions for their improvement. He published his findings in the Flexner Report, which also outlined his standards for admission and the medical school curriculum. More than a third of medical schools — which had failed to meet the report’s standards — shut down as a result.

Born in Louisville, Kentucky to German-Jewish immigrants, Flexner studied Greek, Latin and philosophy at Johns Hopkins University. After graduating in just two years, he returned home and opened his own school, which offered small classes designed to help students gain acceptance into the best universities. Its stellar track record attracted lots of attention — including Carnegie Foundation president Henry Pritchett.

Flexner had never stepped foot in a medical school. But Pritchett viewed poor medical training as a problem of education — and he thought any anger generated would be less severe if a non-physician wrote it.

To prepare for his task, Flexner immersed himself in Theodore Billroth’s book, Medical Education in the German Universities, which described medicine as a primarily scientific discipline, in which physicians were trained in laboratory research as a foundation for clinical training in university hospitals.

Flexner saved the harshest criticism for Chicago’s 14 medical schools, which he described as “a disgrace to the State whose laws permit its existence… indescribably foul … the plague spot of the nation.” But he praised Johns Hopkins, Case Western University and the University of Michigan, among others.

Then, from 1909 to 1910, Flexner journeyed to every medical school in the U.S. and Canada. He pored over student records to check whether they had met admissions requirements, inspected laboratory equipment, and asked how many faculty members had actually received medical training themselves.

Flexner wrote scathingly about the poor quality of instruction in most schools: “Each day students were subjected to interminable lectures and recitations … delivered in methodical fashion by a part-time teacher. If fortunate enough to gain entrance to a hospital, they observed more than participated.”

Flexner assigned medical schools to one of three categories. The first consisted of those that compared to Johns Hopkins — deemed “the model of medical education” — while the second included substandard schools that could be salvaged with financial assistance. And he rated a third group of schools so low that he recommended they be closed immediately.

Medical schools continue to follow his recommendations on students and faculty. To gain admission to medical school, Flexner wrote, applicants should complete least two years of college, with classes in chemistry, biology and physics. He also recommended hands-on learning and the integration of lab and clinical training, the latter at a medical school-owned hospital. The staff should consist of full-time faculty members — “barred from all but charity practice” — who dedicated their lives to teaching and research. Flexner also believed that medicine should be preventive, not just curative.

Did the Flexner Report overlook the ethos of medicine in its blind passion for science and education?

But Johns Hopkins founding professor William Osler found Flexner’s emphasis on research too narrow. And Yale University professor of medicine Thomas Duffy notes in a recent review article that patients’ trust in doctors has eroded over the past 50 years, asking, “Did the Flexner Report overlook the ethos of medicine in its blind passion for science and education?”

In response, many medical schools have begun offering courses in patient communication, medical ethics and medical humanities. And maybe those changes are working; a 2011 Gallup poll found that trust in doctors is at an all-time high, with 70% of respondents rating their level trust as “high” or “very high.”

Regardless of its unintended consequences, Flexner’s 300-plus page report professionalized and reformed the field of medicine. As patients, those strict, rigorous standards have made us not only breathe easier, but live a little healthier, longer.